BILL ANALYSIS                                                                                                                                                                                                    




                   Senate Appropriations Committee Fiscal Summary
                           Senator Christine Kehoe, Chair

                                           354 (Arambula)
          
          Hearing Date:  6/28/2010        Amended: 6/23/2009
          Consultant: Katie Johnson       Policy Vote: Health 9-0
          _________________________________________________________________ 
          ____
          BILL SUMMARY:  AB 354 would delete certain age limits for  
          specified childhood immunizations required for admission to  
          schools.
          _________________________________________________________________ 
          ____
                            Fiscal Impact (in thousands)

           Major Provisions         2010-11      2011-12       2012-13     Fund
                                                                  
          Medi-Cal vaccination     likely $0  $300 - $875        $300 -  
          $875          General/*
          administrative fee                                     Federal

          School reimbursement     likely $0  $706 - $2,100      $706 -  
          $2,100 General**
          for vaccine confirmation

          Potential increased ADA  likely $0           $50 - $550$50 -  
          $550          General**

          *Costs would be shared 50 percent General Fund and 50 percent  
          federal funds.
          **Counts toward Proposition 98 guarantee
          *** Since potential costs to this bill would occur only if CDPH  
          made a decision to promulgate regulations to update its  
          immunization requirements, the fiscal years in which potential  
          costs and savings would occur are unknown and would depend on  
          when CDPH regulations went into effect.
          _________________________________________________________________ 
          ____

          STAFF COMMENTS: This bill meets the criteria for referral to the  
          Suspense File.
          
          Existing law prohibits a school from admitting any person as a  
          pupil unless he or she has been fully immunized, as specified.  
          Some of the diseases need not be documented based on the age of  










          the child.

          This bill would delete those specified age restrictions in  
          statute. The changes would be as follows. Currently, school  
          districts need not document: 
             1)   Haemophilus influenzae type b for children over 4 years  
               and 6 months of age,
             2)   Mumps for children over seven years of age, 
             3)   Pertussis (whooping cough) for children over seven years  
               of age, and,
             4)   Hepatitis B for all children above the kindergarten  
               level. 

          The California Department of Public Health (CDPH) uses both  
          statute and regulation to define "fully immunized." Although  
          this bill would eliminate age restrictions in statute, they  
          would continue to exist in regulation. The deletions of the age  
          restrictions in this bill would permit CDPH to modify the  
          existing immunization requirements via regulations for those  
          diseases that were age restricted. Without this bill, CDPH would  
          not be able to administratively promulgate regulations to update  
          the requirements in regulation. With 
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          AB 354 (Arambula)

          the passage of this bill, CDPH could make an administrative  
          decision to update its regulations to align them with the  
          Centers for Disease Control and Prevention (CDC) recommendations  
          for childhood vaccinations.

          The existing immunization requirements in regulation generally  
          follow the vaccine schedule recommended by the CDC. Of the  
          diseases with age restrictions listed above, pertussis is the  
          only disease for which the CDC recommends a vaccine that CDPH is  
          currently restricted by statute from adding to its regulations.  
          The CDC recommends that a child aged 11 or 12 years receive a  
          pertussis booster shot, also known as Tdap, a vaccine for  
          tetanus, diphtheria, and acellular pertussis. Additionally, CDPH  
          regulations currently recommend, but do not require, that  
          children entering 7th grade receive a Td shot, a vaccine against  
          tetanus and diphtheria. The CDC now recommends Tdap in lieu of  
          Td.

          According to a June 23, 2010, CDPH press release that urges the  
          population to get vaccinated for pertussis, pertussis infections  
          affect the population in cycles that peak every two to five  










          years. The last peak in California was in 2005 with 3,182 cases  
          reported and seven deaths. As of June 15 of this year, 910 cases  
          have been reported and five infants have died. The CDPH website  
          advises Californians that children need 5 doses of DTaP vaccine  
          by kindergarten (ages 4-6) and one dose of Tdap booster by age  
          11 or 12. It also recommends Tdap for teens and adults up to age  
          65.

          Since this bill is not specific to pertussis, it would also give  
          CDPH flexibility to be able to update its regulations in the  
          future to conform with any updated CDC recommendations with  
          regard to those diseases specified in statute.

          This bill would also update the names of the entities whose  
          guidelines CDPH is required to consider when deeming vaccines  
          for additional diseases appropriate for requirement and would  
          add the American Academy of Family Physicians to that list.

          Medi-Cal Potential Costs and Savings

          If CDPH made an administrative decision to update its  
          regulations to require all 7th graders to have received a  
          pertussis booster shot prior to entering school, there would be  
          costs to the Medi-Cal program, which pays a $9 administrative  
          fee to physicians who administer vaccines to Medi-Cal  
          beneficiaries. All other costs related to vaccines for Medi-Cal  
          beneficiaries under age 19 are paid for by the federally-funded  
          Vaccines for Children program. 

          Based on 2006 Medi-Cal counts, 188,379 children were 11 years  
          old. Also, according to January 2009 Medi-Cal population data,  
          an average of approximately 140,000 were in each age year for  
          children aged 11 - 18. According to a 2008 National Immunization  
          Survey of 13 - 17 year old immunization rates, approximately  
          43.7 percent of California adolescents had received the Tdap  
          vaccine and 71.3 percent had received either the Td or Tdap  
          vaccine. To achieve a benefit to the population where there are  
          enough people vaccinated against pertussis to where their  
          immunization would protect those people 

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          AB 354 (Arambula)

          who were not immunized, referred to as "herd immunity",  
          approximately 90 - 95 percent of the population must be  
          vaccinated against pertussis.











          Assuming 1) there were 140,000 - 190,000 7th grade Medi-Cal  
          beneficiaries in any given year, 2) that 43.7 percent of them  
          would have been vaccinated with Tdap without this bill, and 3) a  
          goal to immunize 95 percent of the population, costs to  
          vaccinate 51.3 percent of Medi-Cal 7th graders would be  
          approximately $645,000 - $875,000 in total funds, or $325,000 -  
          $440,000 in General Funds and $325,000 - $440,000 in federal  
          funds. 

          As mentioned above, 71.3 percent of California adolescents had  
          received either Td or Tdap in 2008. The CDC now recommends Tdap  
          in lieu of Td. For those children who would receive the  
          recommended Td vaccination prior to 7th grade, costs would be  
          neutral, essentially an exchange of a shot for a shot. Assuming  
          1) there were 140,000 - 190,000 7th grade Medi-Cal beneficiaries  
          in any given year, 2) that 71.3 percent of them would have been  
          vaccinated either with Td or Tdap without this bill, 3) that  
          those who would have received Td would now receive Tdap upon the  
          passage of this bill, and 4) a goal to immunize 95 percent of  
          the population, costs to vaccinate 23.7 percent of Medi-Cal 7th  
          graders would be approximately $300,000 - $405,000 in total  
          funds, or $150,000 - $200,000 in General Funds and $150,000 -  
          $200,000 in federal funds.

          In addition to the predictions above, it is also possible that a  
          Medi-Cal beneficiary may have received a Tdap booster shot, but  
          does not appear in Medi-Cal claims data. For example, county  
          health departments and clinics often offer free vaccines to the  
          public. If Medi-Cal beneficiaries received the vaccine through a  
          means other than a Medi-Cal physician, costs to the program  
          could be less than estimated above.

          If CDPH chose to require Tdap upon admission to 7th grade and  
          promulgated the regulation to require the whole cohort of  
          adolescents aged 11-18 in Medi-Cal to receive a catch-up Tdap  
          shot in order to attend school in the fall of the fiscal year in  
          which CDPH adopted the regulation, there could be a significant  
          one-time cost to Medi-Cal in an amount up to 6 times that  
          predicted for a single cohort of 7th graders. However, the  
          potential of savings would increase since inoculating all  
          adolescent Medi-Cal beneficiaries could significantly decrease  
          the risk that Medi-Cal would need to treat pertussis in the  
          future for this population.

          There could be unknown, potentially significant future Medi-Cal  










          savings to the extent that this immunization requirement led to  
          decreased incidences of disease, diagnosis, treatment,  
          hospitalization, and death of Medi-Cal beneficiaries. 

          School Potential Costs
          
          In 2000, the Commission on State Mandates approved reimbursement  
          for schools that were required to check that 7th graders had  
          received their Hepatitis B vaccination. Reimbursement was  
          approved at approximately $4.42 per dose for 2008-2009. Costs  
          could be similar for requiring that schools check for pertussis  
          vaccination prior to 7th grade entrance. However, the Hepatitis  
          B vaccination is given in 3 doses; Tdap is only 
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          AB 354 (Arambula)

          one. Therefore, staff estimates that it is reasonable to assume  
          that schools could be reimbursed at about $1.47 per dose. In a  
          February 2010 report by the Legislative Analyst's Office on  
          reforming state reimbursement of K-14 school mandates that  
          discussed the funding, modification, and elimination of the  
          mandates, it was recommended that the state fund school  
          immunization mandates, including the 7th grade check for  
          Hepatitis B.

          According to the California Department of Education's website,  
          there were about 480,000 7th graders in California in 2008-2009.  
          If CDPH were to require schools to check and document for an  
          additional vaccine upon entrance to 7th grade, such as the  
          pertussis booster, at $1.47 - $4.42 per dose, it could cost  
          approximately $706,000 - $2.1 million annually. Additionally, if  
          CDPH were to require schools to not only annually check 7th  
          graders for pertussis immunization, but were to also require  
          them to check and document pertussis immunization for all of  
          California's estimated 2.5 million children in 8th - 12th grades  
          to ensure as many children were immunized as possible, it could  
          cost approximately $3.7 million - $11.1 million one-time.  
          Ongoing, annual costs would only be the 7th grade cost. The  
          Commission on State Mandates could determine that this would be  
          a reimbursable mandate.

          Additionally, to the extent that this bill would prevent  
          children from missing days of school due to illness, the state  
          could incur costs of approximately $33 per student per day. The  
          incidence of pertussis varies from year to year and from state  
          to state. The following estimate is based of a range of 10 to  










          130 in 100,000 students. If 10 in 100,000 students were to no  
          longer miss an average of 5.5 days, as reported by  
          Massachusetts, 
          of school annually for pertussis, the state could need to pay  
          school districts an additional $50,000 in average daily  
          attendance (ADA) annually. If 130 in 100,000 students were to no  
          longer miss an average of 5.5 days of school annually for  
          pertussis, the state could need to pay school districts an  
          additional $550,000 in average daily attendance (ADA) annually.